Death Risk Jumps by 400 Percent for Medicare Cardiac
Patients Who Get Blood Transfusion
Their risk of infection doubles; health care
reformers may look at variation in hospitals
Aug. 5, 2009 – The analysis of nearly 25,000
Medicare patients in Michigan suggests that blood transfusions for
hospitalized cardiac patients should be a last resort, because they
double the risk of infection and increase by four times the risk of
death.
The study also showed that transfusion practices
after heart surgery varied substantially among hospitals, a red flag
that plays into the health care reform debate.
A wide variation in care is a hot-button issue, as
lawmakers and health reform experts discuss the best ways to address the
variations. Some experts believe the country needs a system of medical
guidelines, supported by scientific evidence, to aid doctors in
decision-making.
In fact, the Institute of Medicine has called for a
national initiative of comparing the benefits and harms of certain
methods to improve the delivery of care -- an effort referred to by
health-care insiders as "comparative effectiveness" research.
Blood transfusion is an area that could be well
served with stronger, research-based guidelines, since the current
clinical practice is all over the map, said study co-author Neil
Blumberg, M.D., professor of Pathology and Laboratory Medicine and
director of Transfusion Medicine at the University of Rochester Medical
Center.
"Doctors are simply doing what they were trained to
do, but it turns out that their actions are more harmful than helpful in
many cases," Blumberg said. "This is an instance in which clinical
practice got way ahead of research. And changing the liberal use of
transfusions is going to be difficult despite the evidence showing it is
usually not essential."
The study was published July 31, 2009 in the
journal, BMC Medicine. It was designed to assess patient outcomes as
well as hospital variation in blood use.
Blumberg and lead author Mary Rogers, Ph.D., of the
University of Michigan Health System, analyzed patient records in 40
hospitals, from admission to 30 days after discharge. All had received
coronary artery bypass graft surgery from 2003 to 2006. They found that
30 percent of variation in transfusion practices seemed to be due to
widely varied practices among hospital sites.
Also, blood use among women patients ranged from
72.5 percent to 100 percent, and blood use among men varied from about
50 percent to 100 percent. Transfusions with donor blood were associated
with infections of the genitourinary system, respiratory tract,
bloodstream, digestive tract and skin, the study said.
The risk of death in the hospital was nearly 5
times greater among patients who received a blood transfusion, and the
risk of death in the next 30 days was nearly three times greater. Some
of the risk may've been due to the underlying condition that led to
transfusion but an increasingly convincing body of evidence demonstrates
that some of the effect is almost certainly due to the transfusion
itself, Blumberg said.
Blood transfusions are extremely common in the
United States. Some of the typical reasons for transfusions include
prevention of anemia and improving oxygen delivery in heart failure.
Blumberg has been a long-time advocate for fewer
transfusions and, when they are necessary, for using blood from which
the donor's white cells have been removed. This process, called
leukoreduction, is believed to diminish the chances of infection and
inflammation, research has shown.
"Blood transfusions are certainly necessary in
life-threatening situations," Blumberg said. "But this study and other
studies confirm they should be a last resort, not a first resort, as
they often are."
For decades the URMC has been a leader in the study
of blood transfusions, and Strong Memorial Hospital at URMC was among
the first in the country to begin using leukoreduced blood for all its
patients.
More recently, a team at Strong began to further
refine the guidelines for blood transfusion. As a result the hospital
has already seen a 10 to 15 percent drop in transfusions during the past
six months. The improvement program is still in its early stages, and
Blumberg said they will closely monitor the use of transfusions at
Strong in the coming months.
